[CRT-FORUM] 23E CRT and pulmonary hypertension. Dr. Perez Riera

[CRT-INFO]

Dear Dr. Carlos Rodriguez Artuza from Maracaibo Venezuela.
Secondary Pulmonary Arterial Hypertension (PAH) is a marker of advanced 
heart failure (HF) that confers a poor prognosis. Many patients with 
advanced HF are ineligible for orthoptic cardiac transplantation because 
of fixed PAH. Cardiac Resynchronization Therapy (CRT), by stimulating 
the right atrium, and right and left ventricles, is a therapy that 
effectively palliates symptoms in patients with HF. CRT increases 
cardiac output and decreases pulmonary capillary wedge pressure, thus 
partially reversing hemodynamic abnormalities that lead to secondary PAH 
in many HF patients(1). Additionally, CRT significantly reduces central 
sleep apnea in patients with HF with a decrement of pulmonary artery 
systolic pressure correlated to drop in central sleep apnea (2).

CRT improved cardiac function and reduced the apnea-hypopnea index. 
Reduced circulatory delay likely stabilized ventilatory control systems 
and may represent a new therapeutic target in obstructive sleep 
apnea(3). In patients receiving CRT, although elevated estimated 
pulmonary artery systolic pressure (ePASP ? 50 mmHg) does not 
significantly impact LV reverse remodeling, it is associated with an 
adverse long-term outcome(4).
Elevated baseline Systolic Pulmonary Arterial Pressure in patients who 
underwent CRT is an independent predictor of all-cause mortality or 
transplantation and HF admission. A decrease in Systolic Pulmonary 
Arterial Pressure on follow-up echocardiography is an independent 
positive prognostic marker(5).
In patients with chronic HF, venous pulmonary congestion is an important 
determinant of systolic PAH. Hemodynamic and Doppler determinants showed 
similar predictive power in identifying systolic PAH (6).

References
1) Healey JS, Davies RA, Tang AS. Improvement of apparently fixed 
pulmonary hypertension with cardiac resynchronization therapy. J Heart 
Lung Transplant. 2004 May; 23: 650-652.
2) Yiu KH, Lee KL, Lau CP, Siu CW, Miu KM, Lam B, Lam J, Ip MS, Tse HF. 
Alleviation of pulmonary hypertension by cardiac resynchronization 
therapy is associated with improvement in central sleep apnea. Pacing 
Clin Electrophysiol. 2008 Dec;31:1522-1527.
3) Stanchina ML, Ellison K, Malhotra A, Anderson M, Kirk M, Benser ME, 
Tosi C, Carlisle C, Millman RP, Buxton A. The impact of cardiac 
resynchronization therapy on obstructive sleep apnea in heart failure 
patients: a pilot study. Chest. 2007 Aug;132:433-439.
4) Stern J, Heist EK, Murray L, Alabiad C, Chung J, Picard MH, Semigran 
MJ, Ruskin JN, Singh JP.Elevated estimated pulmonary artery systolic 
pressure is associated with an adverse clinical outcome in patients 
receiving cardiac resynchronization therapy. Pacing Clin Electrophysiol. 
2007 May; 30:603-607.
5) Shalaby A, Voigt A, El-Saed A, Saba S. Usefulness of pulmonary artery 
pressure by echocardiography to predict outcome in patients receiving 
cardiac resynchronization therapy heart failure. Am J Cardiol. 2008 Jan 
15; 101: 238-241.
6) Capomolla S, Febo O, Guazzotti G, Gnemmi M, Mortara A, Riccardi G, 
Caporotondi A, Franchini M, Pinna GD, Maestri R, Cobelli F. Invasive and 
non-invasive determinants of pulmonary hypertension in patients with 
chronic heart failure. J Heart Lung Transplant. 2000 May; 19: 426-438.

All the best for all
Andrés Ricardo Pérez Riera.MD
Chief of electrovectorcardiographic sector. ABC’s Medical School, ABC 
Foundation, Santo André, São Paulo, Brazil
Riera at uol.com.br

> Greetings and congratulations beforehand, once again.
>
> I would like to know the opinion of the experts on the approach to 
> patients
> that meet criteria for the implantation of a resynchronization device, 
> who
> also have pulmonary hypertension, since there is little mentioned in the
> studies and in the international guidelines about this.
>
> Dr Carlos Rodriguez Artuza
> IECTAS. Maracaibo Venezuela.
>


-- 
Dr. Sergio Dubner
President of Scientific Committee

Dr. Edgardo Schapachnik
President of Steering Committee